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!i APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED �j (Complete in Triplicate', Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address el City Lot Size Q �SPhone Owner's Name Address f �t. r o Contractor Addres License No! Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ O� DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial '17 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑.Tracy Type of Casing} Specifications (-I Public Cl1Other ❑ Delta Depth of GroutSealType of Grout _ I Irrigation ._Approx.-Depth I 1 Eastern Surface Seal Installed by - Repair Work Done 17 Type of Pump H,P. State Work Done z Well Destruction ❑ Well Diameter_ Sealing Material atop 50') Depth Filler Material IBelow 56 TYPE OF SEPTIC WORK: NEW INSTALLATION ( REPAIR/ADDITION 1 1 DESTRUCTION I i INo septic system permitted if public sewer i available within 200 feet.) Installation will serve:�Residence'� Commercial Otfier r Number of living units: —1—.,`Number of drooms Character of soil to a depth 3 of feet: Water table depth SEPTIC TANK ❑ !0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal distance to neatest: "Vtilell' Foundation' / Property Line A00 I LEACHING LINE n 1 No. & Length of lines Total,,length/size 0 FILTER BED ❑ Distarice to nearest: Well - Foundation Property Line VLa 0 SEEPAGE PITS { I Depth 2 e Number SUMP ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ` Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st for r uira i spections. C m to drawing :nverse side. XF7 I Signed X Title: [[�� Date: 1 y FOR DEPARTMENT USE ONLY f Application Accepted by €` �&� Date rea [' Pit or'Grout Inspection by ! Date Final Inspection by Date ?-74 7 II Additional Comments: - 1 0 Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies'to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT.REMITTED CK RECEIVED BY DATE PERMI7'NO. F INFO CASH + EH 13-2 IREV.t H5Y 0/—�� EH 14-28